Trainer Application Interested in providing NeurOptimal® neurofeedback for First Responders in your community? Please complete the form below, and we will be in touch shortly! Name * First Name Last Name Company Name * Email * Phone * (###) ### #### Company Website * http:// Company Description and List of Services * Provide a brief description of your company and list the services you offer. Office Location(s) * Specify the location(s) of your office. Service Area (Geographic) * Specify the geographic area(s) your cover. Provide City/State or radius (eg, +/- 10-25 miles) for metropolitan areas. Certified Level * Specify your certification level. Basic Certification (9 months experience required) Advanced Certification Office: Ability for In-office Training * Do you offer in-office training? Yes No On-Site: Ability for On-site Training * Can you travel for on-site training? Yes No Initial Orientation: 4 Hours of Training Agree to provide 4 hours of orientation training. Yes No Ongoing Training: 1 Hour/Quarter * Agree to provide ongoing training for 1 hour per quarter. Yes No Monthly Reporting through Neurofeedback Stats * Agree to provide monthly reports using HIPAA-compliant solution(s) to track Concerns and Shifts. Yes No Reimbursement Schedule * Agree to 30-day net reimbursement from the date(s) of training. Yes No Insurance * Agree to carry liability insurance naming FRN as additional insured. Yes No Thank you for your application. We will respond within 24 hours.
